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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address D CitLot Size PM Owner's Name t�!(fl �. /]r � �'• Address ""• ! V��'7 Phone " f a , � Contractor Address d. License iVo. Phone TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 5 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INE . DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU T E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS" ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing {� © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,Specifications Y 1 g F] Public Ll Other �_ l Delta '-Depth of Grout Seal Type of Grout E I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 ' r Depth Filler Material (Below 50') ! TYPE OF SEPTIC WORK: NEW INSTALLATION r.7 REPAIR/ADDITION l I DESTRUCTION I ) INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial Number of living units: Number of bedrooms A- . Character of soilto a depth of 3 feet: Water table depth SEPTIC TANK `' _'❑ Type/Mfg `' } Ca6acitvZW19 No. Compartments PKG. TREATMENT PLT 0 ,. -� Method of Dispo I Distance to nearest: Well /`Foundation 12 Property Line/ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 1 SUMPS L7 Distance to nearest: Well Foundation J�DProperty Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ani rules and regulations of the San Joaquin Local Health Diltrict. ' + l Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 11 certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject tolworkman's Compensa- tion laws of California." / The applicant Wst call for all uired in ctions. Complete drawing on reverse side.f �, Signed X Title: �' {iL-+y i f Dater CEJ' S I`ORARTMENT USE E7NI_Y # ` Application Accepted by _ _ Date Area Pit or Grout Inspection by } bate Final Inspection by 1 ""Date Additional Comments: T � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑,Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 A Tom', �--� IFEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. LI +,E H 13-24 1REV.i/H 51 7•� / /��r�� "�- 1 �� EH 14-28 V [/ IIJVJ Cil!